Form F-2 (JUVENILE JUSTICE) "Medical Examination Report" - North Carolina

What Is Form F-2 (JUVENILE JUSTICE)?

This is a legal form that was released by the North Carolina Department of Justice - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2015;
  • The latest edition provided by the North Carolina Department of Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-2 (JUVENILE JUSTICE) by clicking the link below or browse more documents and templates provided by the North Carolina Department of Justice.

ADVERTISEMENT
ADVERTISEMENT

Download Form F-2 (JUVENILE JUSTICE) "Medical Examination Report" - North Carolina

Download PDF

Fill PDF online

Rate (4.4 / 5) 70 votes
CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
CRIMINAL JUSTICE STANDARDS DIVISION
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Fax (919) 779-8210
MEDICAL EXAMINATION REPORT
Form F-2 (Juvenile Justice)
(Rev.10/15)
This information is for official use only and will not be released to unauthorized persons. Payment for services
rendered is the responsibility of the hiring agency or the individual. The Criminal Justice Standards Division is
NOT responsible for payment. Mail form to hiring agency or individual. DO NOT mail form to Criminal Justice
Standards Division.
o be completed by either a Physician/Physician’s Assistant/Nurse Practitioner or Surgeon licensed to
Instructions: T
practice medicine in N.C. or by a Physician and/or Surgeon authorized to practice medicine in accordance with the
rules and regulations of the U.S. Armed Forces, following an actual physical examination. The original or a copy of
this report must be retained in personnel file by the appointing agency.
Date:
___________________
Name: ___________________________________________________
Date of Birth: _________________________
Last
First
Middle
Well nourished
Height: ____________
Weight: ____________
Obese
Muscular
VISION
Visual Acuity: If applicant wears glasses or contacts, test and record acuity with and without glasses
Without glasses:
R - 20 / ____________
L- 20 / ___________ Both - 20 / ____________
With glasses:
R - 20 /
__________
L- 20 / ___________ Both - 20 / ____________
With contacts:
R - 20 /
__________
L- 20 / ___________ Both - 20 / ____________
How long have contacts been worn? _____________________
Depth Perception:
Normal
Abnormal:
___________________________________
Color Perception:
Normal
Abnormal:
___________________________________
Peripheral Vision:
Normal
Abnormal:
___________________________________
HEARING
Hearing Acuity:
Audiogram - or -
15' whispered conversation (check one)
Right ear:
Normal
Abnormal:
____________________________________
Left Ear:
Normal
Abnormal:
____________________________________
(Continued next page)
CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
CRIMINAL JUSTICE STANDARDS DIVISION
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Fax (919) 779-8210
MEDICAL EXAMINATION REPORT
Form F-2 (Juvenile Justice)
(Rev.10/15)
This information is for official use only and will not be released to unauthorized persons. Payment for services
rendered is the responsibility of the hiring agency or the individual. The Criminal Justice Standards Division is
NOT responsible for payment. Mail form to hiring agency or individual. DO NOT mail form to Criminal Justice
Standards Division.
o be completed by either a Physician/Physician’s Assistant/Nurse Practitioner or Surgeon licensed to
Instructions: T
practice medicine in N.C. or by a Physician and/or Surgeon authorized to practice medicine in accordance with the
rules and regulations of the U.S. Armed Forces, following an actual physical examination. The original or a copy of
this report must be retained in personnel file by the appointing agency.
Date:
___________________
Name: ___________________________________________________
Date of Birth: _________________________
Last
First
Middle
Well nourished
Height: ____________
Weight: ____________
Obese
Muscular
VISION
Visual Acuity: If applicant wears glasses or contacts, test and record acuity with and without glasses
Without glasses:
R - 20 / ____________
L- 20 / ___________ Both - 20 / ____________
With glasses:
R - 20 /
__________
L- 20 / ___________ Both - 20 / ____________
With contacts:
R - 20 /
__________
L- 20 / ___________ Both - 20 / ____________
How long have contacts been worn? _____________________
Depth Perception:
Normal
Abnormal:
___________________________________
Color Perception:
Normal
Abnormal:
___________________________________
Peripheral Vision:
Normal
Abnormal:
___________________________________
HEARING
Hearing Acuity:
Audiogram - or -
15' whispered conversation (check one)
Right ear:
Normal
Abnormal:
____________________________________
Left Ear:
Normal
Abnormal:
____________________________________
(Continued next page)
(continued)
CARDIOVASCULAR
Blood Pressure: _________________________ Resting Pulse: _________________
Cardiac Examination:
Normal
Abnormal:
__________________
Peripheral Circulation:
Normal
Abnormal:
__________________
ECG:
Indicated by hx or exam:
ABNORMAL DETAILS
NORMAL
HEENT: _______________________________________________________________________________
LUNGS ________________________________________________________________________________
ABDOMEN: ____________________________________________________________________________
MUSCULOSKELETAL: __________________________________________________________________
GENITOURINARY: ______________________________________________________________________
NEUROLOGICAL:_______________________________________________________________________
SKIN: _________________________________________________________________________________
URINALYSIS
Normal
Abnormal: __________________________________________________________
TB SKIN TEST
Negative
Positive _____________________________________________________________
Are there any conditions, physical, emotional or mental, which, in your opinion, suggest further examination?
No
Yes:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Do you have any reservations about this candidate’s ability to physically perform required duties?
No
Yes:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
I have read and fully understand the Medical Screening Guidelines Implementation Manual for the certification Of
Juvenile Justice Officers and Chief/Juvenile Court Counselors in the State of North Carolina.
________________________________________________________________________________________________
Signature of Physician/Physician’s Assistant/Nurse Practitioner
Date
Name and Address of Physician/Physician’s Assistant/Nurse Practitioner - Typed
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Form F-2 (Juvenile Justice), Rev. 10/15
Page of 2